Look Inside Part 1: Taking Apart A Call

One of the best things about success is that it feels really good. It also serves as confirmation. Whether it's hitting a baseball, singing in perfect pitch or solving a mathematical quandary, success confirms that your investment of time and energy in learning whatever it was you set out to learn has paid off.

But there is a strange downside to success that is often not considered: Little to no learning actually comes from success. While it is true that learning brought about success in the first place, it is also true that a successful endeavor doesn't have much learning potential. It is failure, challenge and adversity where often-incredible learning and growth opportunities truly lie.

Knowing where those learning opportunities are, the real challenge then becomes extracting the most learning you can from every call you run, every chance you can, if you wish to improve your medicine on an ongoing basis. This month in BTB we will look at a simple four-step process to quickly disassemble and examine your performance on any given call. Properly phrased, this look inside is termed introspection. Again, a strange side to introspection is that it cannot be forced on anyone. It only occurs when a person chooses to do it.

That being said, let's look at this handy four-step process. For the sake of discussion, consider a call where the patient collapsed midway through the patient assessment process:

1. What aspects of this call went particularly well?

Let's say on the plus side you did a solid assessment, wrote a great patient care report (PCR) and had a succinct and meaty hand-off report at the hospital.

2. What aspects of this call went poorly/not so well?

On the minus side, you didn't take orthostatic pressures and, as a result, failed to recognize the impending signs of cardiovascular collapse until the patient slid off the couch onto the floor. That left no option but intraosseous to establish vascular access. Had you been on your game, you would have cannulated the patient's A/C with an 18-gauge or better while he was still conscious, but not today.

3. What part(s) of the call would you change?

Clearly, you would have established vascular access much earlier in the process, when the patient's blood pressure was better and he was perfusing better as well.

4. How would this have changed the overall outcome of the call/patient?

For this call, it would have allowed the patient to undergo a basic IV start vs. the more invasive intraosseous approach, in the end reducing the risk of infection. Though it doesn't actually impact patient outcome, basic IV access is also significantly cheaper than IO, so there are cost savings to be had as well.

As you can see, with just a quick run through four short-answer questions, you can dissect any call into mentally digestible bites. Once it's mentally manageable, you can critically look at your performance and see where changes could have been made. Particularly intriguing to me about this model is that it works on any element of a call. If you can be introspective enough to honestly and accurately look at your work, you can identify and solve problems with any component of prehospital medicine: patient assessment, critical thinking, clinical decision-making, technical skills, whatever.

It's also important to remember sequencing as you work the questions. Look at the positive elements first to see what went well. Like I said, there may be little to nothing to learn, but you can still celebrate the successes, as you well should. Then look at the problem du jour, whatever it is. As you consider what you would change about the call, look at each possible change and carefully think through the cause/effect process, e.g., "Had I put the patient on oxygen sooner, he would have been less confused and I would have gotten much better patient information." Or, "If had given my patient the Zofran before that hilly, really curvy stretch of road, I probably wouldn't have his spaghetti dinner all over my pants."

In the end, this matter of introspection really comes down to whether you want your practice of prehospital medicine to continue to grow and mature. If you do, are you willing to put forth the time and energy to accomplish the task? Then you will find that routinely assessing your work will yield tremendous benefits in the long run.

With this approach, you can critically look at your medicine on a call-by-call basis. What's really valuable is that this process isn't just a Band-Aid; it truly helps you find solutions. For example, when you get a question wrong on an exam, it is important to learn the right answer to that question. But even more important is to understand what led you to make the wrong choice in the first place.

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.